Technology-enhanced monitoring in psychotherapy and

e-mental health
STEPHANIE BAUER & MARKUS MOESSNER
Center for Psychotherapy Research, University Hospital Heidelberg, Heidelberg, Germany
Abstract
Advances in technology increasingly facilitate data collection in the context of psychosocial and
psychotherapeutic care. Such technology-enhanced assessments (e.g. via Internet-based systems and
mobile devices) open new perspectives for research into processes related to mental health and
well-being. The use of this knowledge for the development and refinement of (online and face-to-
face) therapeutic interventions promises to contribute to an optimization of care. The aim of this
paper is to provide an overview on how information and communication technologies may be used
(a) to improve our understanding of illness development and recovery through longitudinal technol-
ogy-enhanced assessment of symptoms and behaviors (e.g. outcome monitoring and ecological
momentary assessment) and (b) to optimize care for mental disorders by integrating such monitoring
assessments in specific interventions (e.g. ecological momentary interventions and supportive
monitoring) in face-to-face or e-mental health settings.
Keywords: mental health, monitoring, ecological momentary assessment, e-mental health
The increasing availability of information and communication technologies (ICTs) has
opened new perspectives for the prevention, self-help and treatment of mental disorders
(e-mental health). In addition, it has led to newoptions for the assessment of relevant symp-
toms, attitudes and behaviors within such e-mental health interventions as well as within the
context of regular (face-to-face) care. Through ICT-based systems, it has become feasible
and efficient to conduct longitudinal assessments at short time intervals (e.g. weekly or daily
assessments). Such assessments considerably improve our knowledge of the processes of
illness development and recovery by allowing for a detailed description of symptom courses
over time. In addition to the description of such courses, ICT-based systems also allow for
the usage of the collected information in a timely way (e.g. during treatment) as the results
of the assessments are immediately available to interested parties (e.g. researchers and
clinicians). This paper addresses both these topics and has two specific objectives: to illustrate
how the ICT-based longitudinal assessment of specific indicators such as symptoms and
behaviors may be used to enhance our understanding of mental illness and to describe how
ICT-based monitoring systems may be used to enhance psychosocial and psychotherapeutic
care in both face-to-face and e-mental health settings. To this end, we introduce several
concepts and methodologies that have contributed to one or both of these topics.
Correspondence: Stephanie Bauer, Center for Psychotherapy Research, University Hospital Heidelberg, Bergheimerstr. 54, 69115
Heidelberg, Germany. Tel: +49-6221-567612. Fax: +49-6221-567350. E-mail: stephanie.bauer@med.uni-heidelberg.de
Journal of Mental Health, August 2012; 21(4): 355363
2012 Informa UK, Ltd.
ISSN: 0963-8237 print / ISSN 1360-0567 online
DOI: 10.3109/09638237.2012.667886
Outcome monitoring
For several decades, prepost assessments have been the standard practice in psychotherapy
outcome research. In the 1990s, health political initiatives that required the implementation
of quality assurance measures into health services led to the development of programs that
systematically assessed the treatment outcome in routine care. These initiatives also resulted
in a shift from the pure evaluation of therapy outcome toward the continuous monitoring of
psychotherapy progress (Percevic et al., 2004). Over the past 20 years, several computer
systems have been developed to facilitate progress and outcome monitoring in large
patient samples under routine care conditions (e.g. Barkham et al., 2001; Kordy et al.,
2001; Lambert et al., 2001a; Lueger et al., 2001; Percevic et al., 2004) and a number of
research programs have addressed the question as to how monitoring a patients progress
may help to ultimately improve the treatment outcome. While based on different underlying
models, it has been demonstrated by independent research groups that the provision of
feedback to the therapist based on monitoring information can help to increase treatment
effectiveness and efficiency (e.g. Bauer, 2004; Lambert et al., 2001b, 2003; Percevic et al.,
2006). Future studies will need to address the question by which mechanisms these effects
were reached.
In the following, we introduce one of these models and the corresponding software
program that were both developed at the Center for Psychotherapy Research (University
Hospital Heidelberg, Germany). The background is the StuttgartHeidelberg model,
which was formulated for quality assurance in psychotherapy along with a computerized
data assessment and data management program named Akquasi (Kordy & Lutz, 1995;
Kordy et al., 2001). Starting with assessments at the beginning and end of the treatment
in routine care settings and the provision of feedback on the treatment outcome to providers
(e.g. clinicians and case managers), the system was subsequently expanded using inter-
mediate assessments to allow for continuous monitoring of a patients progress throughout
the course of the treatment (Percevic et al., 2004).
The collectedlongitudinal datawere usedtodefine anempirically basedoutcome monitoring
strategy. By studying the predictive value of early improvements in treatment (early response)
or the lack thereof (early non-response), it was found that at a given point in treatment, the
past symptom course did not predict the future course. In other words, this means that
future progress in treatment (i.e. symptomreduction in a later stage of treatment) was indepen-
dent of past progress (i.e. symptom reduction in an earlier stage of treatment). The analyses of
several German and US American data sets confirmed this finding, which led to the recommen-
dation of a specific outcome monitoring strategy based on a random walk model (Percevic
et al., 2006). This strategy ultimately aims at the adaptive allocation of therapeutic resources
(i.e. treatment sessions) depending on a patients current symptom status in order to enhance
the treatment outcome: in case a patient has reached the intended outcome (e.g. a certain
cutoff score or a functional range in relevant dimensions), treatment termination is rec-
ommended. In case a patient has not yet reached the intended outcome, treatment prolongation
is recommended. Based on the empirical results described above, this strategy, in contrast to
other systems (e.g. Lambert et al., 2001b), does not consider early non-response or symptom
deterioration as an indicator for risk of a negative future symptom course. Therefore, it does
not suggest an alteration of the therapeutic approach or technique, but rather calls for the
provision of additional therapy sessions to maximize a patients chance of reaching the intended
outcome, as future improvements do not dependonimprovements early intherapy. Inaddition,
the approach may contribute to an optimization of the overall treatment efficiency by an
improved allocation of therapeutic resources (Percevic et al., 2004).
356 S. Bauer & M. Moessner
Any outcome monitoring system, regardless of its specific underlying concept, requires a
reliable computerized program to allow for efficient data assessment and data management.
The system Web-Akquasi (i.e. the Internet-based advanced version of the original program
Akquasi) was specifically developed for frequent assessments and timely provision of feed-
back based on several different levels of data aggregation (see below). The system is flexible in
terms of the psychometric instruments that are used. The administration tool allows to
implement user-defined assessments for specific settings (e.g. inpatient or outpatient treat-
ment), target groups (e.g. patients with a specific diagnosis or mixed samples) and measure-
ment plans (e.g. weekly assessments, monthly assessments or follow-up assessments).
Patients (and other user groups, e.g. therapists) complete assessments via a common user in-
terface. Figure 1 shows an example of a questionnaire page as it is displayed to the user in
Web-Akquasi. In treatment settings (e.g. in an inpatient unit), typically a staff member
would access the software and open the data entry window for the patient to complete his
or her assessment. For other settings, the program allows to automatically send e-mails to
the participants at pre-defined intervals (e.g. once per month) or time points (e.g. 6
months after discharge from the hospital) reminding them of their assessment and including
a link that takes them directly to the data entry window.
As soon as the patients enter their data, Web-Akquasi evaluates the data and different
forms of feedback are immediately available to the end users (e.g. clinicians or researchers).
These include information on rawand scale scores, their evaluation related to patient or non-
patient norms, courses of specific indicators over time (e.g. impairment level) and the
evaluation of changes from one assessment to another (based on the concept of clinical sig-
nificance; Jacobson & Truax, 1991). Furthermore, the program allows to feed back sugges-
tions concerning treatment continuation based on the random walk model described above.
Examples of feedback are displayed in Figures 24. For a more comprehensive description of
the functions of Web-Akquasi, see Percevic et al. (2004).
Figure 1. Questionnaire page in Web-Akquasi.
Technology-enhanced monitoring 357
Besides its use in quality management, Web-Akquasi has been integrated into a number
of e-mental health programs such as an Internet-based eating disorder prevention program
(ES[S]PRIT; Bauer et al., 2009; Lindenberg et al., 2011), an Internet-based maintenance
and relapse prevention program for eating disorders (EDINA; Gulec et al., 2011) and pro-
grams using therapist-guided chat groups to provide aftercare support to patients following
their discharge from inpatient treatment in hospitals for psychosomatic and psychotherapeu-
tic care (e.g. Bauer et al., 2011). In all these programs, Web-Akquasi automatically schedules
brief monitoring assessments at regular intervals (e.g. once per week) and automatically
sends a link to the questionnaire to the participant, who then completes the questionnaire
online. This allows administrators and counselors to track the participants well-being in rel-
evant dimensions throughout their participation in the respective e-mental health program.
For example, online counselors use the Web-Akquasi feedback tools to get an overview
about a participants course of symptoms before they meet with him/her for a counseling
chat session. In addition, Web-Akquasi serves as an alarm system in these programs,
that is, in case that a participants entries in the questionnaire meet the pre-defined alarm
Figure 2. Web-Akquasi feedback on impairment level and change since the previous assessment.
Notes: Numbers indicate percentiles. Bold (displayed in red) numbers indicate dysfunctional range and non-bold
(displayed in green) numbers indicate functional range. Arrows indicate change. Non-shaded arrows (displayed
in green) indicate no change in the functional range, reliable improvement or clinically significant improvement.
Shaded arrows (displayed in red) indicate no change in the dysfunctional range or deterioration.
Figure 3. Web-Akquasi feedback on changes over time in different symptoms (weekly assessments).
Notes: Lines indicate symptom development over time. Red (top half) indicates dysfunctional range and green
(bottom part) indicates functional range. Scale in percentiles.
358 S. Bauer & M. Moessner
criteria (e.g. in eating disorder programs, a BMI below a certain cutoff or a frequency of
bingepurge episodes above a certain cutoff), Web-Akquasi automatically notifies the
online counselor via e-mail. The counselor may then contact the participant to clarify
the need for more intense support or treatment. Finally, Web-Akquasi also allows to
provide supportive feedback to the participants whenever they complete a monitoring assess-
ment. This component of the program (supportive monitoring) is explained in more detail
below.
In addition to their usage in the above-mentioned contexts of quality management and
e-mental health, programs such as Web-Akquasi have gained increasing importance as
research instruments as they obviously allow for the collection of data that have not been feas-
ible to collect at times of paperpencil assessments. The flexibility increases in line with the
advances in technology. For example, given that Web-Akquasi can be used via mobile
devices (e.g. the participants may complete the online questionnaires on their smartphone),
it can also be used to conduct assessments in the context of the participants everyday lives
outside the laboratory (i.e. ecological momentary assessment (EMA), see below). The avail-
ability of such data will continue to advance our knowledge on illness and recovery processes
and help to refine concepts underlying the monitoring of treatment progress.
Ecological momentary assessment
EMA(Stone &Shiffman, 1994) refers to the techniques that use computer-assisted method-
ology to assess self-reported symptoms, behaviors, or physiological processes while the partici-
pant undergoes normal daily activities (Ebner-Priemer & Trull, 2009; p. 464). EMA is
primarily used as a means for research and has three major advantages: first, data are assessed
Figure 4. Web-Akquasi feedback: changes in several criteria between two assessments against a community norm.
Note: Red (right part) indicates dysfunctional range and green (left part) indicates functional range.
Technology-enhanced monitoring 359
in real time (instead of retrospectively) and within the specific context of interest. Gathering
information retrospectively is associated with different problems that lead to inaccurate data
(e.g. recall may be biased due to mood, affective valence or simply time between an event
and the assessment), which can be avoided by EMA. Several studies showed that using
EMA can increase accuracy and reduce retrospective bias (e.g. Ben-Zeev et al., 2009;
Ebner-Priemer et al., 2006). Second, EMAacknowledges the fact that impairment, symptoms
and behaviors are dynamic phenomena and that their fluctuations over time cannot be cap-
tured accurately by traditional assessment methods (Ebner-Priemer & Trull, 2009). This is
particularly relevant in illnesses that are per se characterized by any form of instability, such
as borderline personality disorder, which is characterized by highly instable affect or
bulimia nervosa in which key symptoms (bingepurge episodes) ebb and flow substantially
over time. Third, EMA allows to collect data simultaneously on several levels, for example,
self-report of symptoms and physiological parameters can be assessed in parallel. This may
further enhance our understanding of a variety of processes related to mental illness.
Nowadays, EMA self-report data are most frequently being collected via mobile devices
such as mobile phones, smartphones and palmtops, which allow for the most flexible assess-
ments in the participants daily lives. At study entry, the participants are instructed to record
the target symptoms or behaviors at certain occasions. These occasions may be defined in
different ways: for example, they may be indicated by a signal (e.g. a text message to their
mobile phone or an acoustic signal of their palmtop) that reminds them to enter their data
at that specific moment. In addition, the participants may be asked to report whenever a
certain symptom or behavior occurs or they may be asked to record their data at a specific
time point each day (Smyth et al., 2007).
EMA is still a relatively new field of research. However, the number of studies that use the
EMAmethodology as a complement to traditional assessments is constantly rising. This prom-
ises to enhance our knowledge on specific symptoms and behaviors related to mental illness,
their interactions and their temporal courses. For example, Smyth et al. (2007) used all three
types of daily self-report mentioned above in a sample of 131 female patients with bulimia
nervosa. Over a 2-week period, the participants recorded their mood, stress level and bulimic
behaviors (binge and vomit episodes). This resulted in thousands of EMA data points and
for the first time allowed to analyze the temporal sequencing of these three indicators.
In addition to the mere assessment of relevant symptoms and behaviors, the EMA tech-
nology is increasingly used as a means to deliver information and support to individuals, for
example, within psychosocial and health behavior treatments (Heron & Smyth, 2010). Such
ecological momentary interventions (EMIs) promise to enhance traditional care in various
ways. Advantages include the opportunity to provide information and support to individuals
in the context of their everyday lives (e.g. between treatment sessions), anytime and any-
where, and the fact that EMI can be tailored based on the participants symptom reports.
A limited number of studies addressing several diagnostic groups and symptoms (e.g.
smoking cessation, weight loss, eating disorders and anxiety) using EMI have been published
so far (for an overview, see Heron & Smyth, 2010), but without any doubt, this number will
continuously increase in the course of the increasing availability of mobile technologies. One
specific form of EMI is the concept of supportive monitoring, which will be described in
more detail in the following.
Supportive monitoring
Supportive monitoring describes an approach that uses continuously assessed information in
order to provide supportive feedback to the participants based on this information. This
360 S. Bauer & M. Moessner
should help the participants to establish or maintain healthy attitudes and behaviors, counter-
act negative developments and improve their self-management competencies in dealing with
their illness.
The concept has been used in several studies using mobile phones and text messaging via
the Short Message Service (SMS). In these programs, the participants report relevant symp-
toms and behaviors at regular intervals (e.g. once a week or once a day) by sending a text
message in a standardized format (i.e. scores that the participants would tick if data were as-
sessed in a paperpencil format). A software program automatically analyzes the incoming
messages based on a specific algorithm, for example, with respect to the participants
status (functional versus dysfunctional) and change compared with the previous assessment
(no change, improvement or deterioration) in the assessed dimensions. Based on this evalu-
ation, the program automatically selects a feedback message from a pool of pre-formulated
statements that is then sent to the participant in response to his or her symptom report.
These messages are supposed to provide a small but constant dose of support to the partici-
pants. They are formulated to reinforce positive developments in the participants symptom
reports and to provide suggestions for self-help or more intense interventions in case of
symptom deteriorations. It is assumed that the approach enhances the participants self-man-
agement strategies by encouraging them to seek more intense support as soon as this need
becomes evident in the monitoring assessments. The supportive monitoring approach
based on text messaging has been used, for example, in interventions for patients with
bulimia nervosa (Bauer et al., 2003, 2011; Robinson et al., 2006; Shapiro et al., 2010)
and in programs to enhance health behaviors in children (Bauer et al., 2010; Shapiro
et al., 2008) and adults (Haug et al., 2009).
A similar approach has been implemented in the above-mentioned Internet-based pro-
grams for the prevention (Bauer et al., 2009; Lindenberg et al., 2011) and maintenance of
treatment gains (Gulec et al., 2011) as well as for the disease management of patients with
recurrent major depression (Wolf, 2011). In these programs, the supportive monitoring com-
ponent is administered via the software Web-Akquasi. As soon as the participants register to
the program, they are automatically notified by e-mail whenever a monitoring assessment is
due. They then click on the link in the e-mail and are automatically directed to the online
monitoring questionnaire. The procedure is equivalent to what has been described for the
SMS-based programs above. The evaluation of the monitoring data follows specific algor-
ithms that have been defined for the various online platforms. Upon completion of the moni-
toring questionnaire, the participants receive their feedback message via e-mail.
Conclusion
The potential of e-health programs has been explicitly addressed in the Health Strategy
adopted by the European Commission (2007) (Together for Health: A Strategic Approach
for the EU 2008-2013), which states that New technologies have the potential to revolu-
tionise healthcare and health systems and to contribute to their future sustainability
(p. 9). In the field of mental health, many promising approaches using various forms of tech-
nologies have been developed and evaluated over the past decade. However, research in this
area is still in its early stage and many questions remain to be addressed by future research.
For example, we need to better understand how these interventions work, who benefits and
who does not, and which approach works best for which target population. Data from con-
tinuous monitoring assessments will help us to study the processoutcome relationships and
topics such as response/non-response and mechanisms and speed of change. Similarly, such
monitoring systems may be used outside of the e-mental health context to further enhance
Technology-enhanced monitoring 361
our knowledge on these aspects with regard to traditional care (e.g. face-to-face counseling
and treatment).
In our view, the biggest potential of e-mental health lies in the combination of technology-
enhanced interventions and traditional care resulting in stepped care approaches that range
across a spectrum of interventions. In such stepped care models, technology-enhanced inter-
ventions seem especially promising prior to routine treatment (e.g. easy-access, low-intense
online interventions may be offered as the initial type of support) and following routine treat-
ment (e.g. online interventions may help individuals to maintain treatment gains once they
are discharged from treatment). Monitoring systems may play a key role in this context and,
ideally, the continuous monitoring of relevant symptoms and behaviors would be considered
an integral part of such stepped care programs. This procedure promises two major advan-
tages: first, it allows to provide continuous support to individuals as described above (sup-
portive monitoring) and, second, it allows to better estimate individuals need for support
and may serve as the underlying information system to guide the decisions about transition
between different levels of care (e.g. by detecting symptom deteriorations and allowing for
timely interventions). This would ultimately lead to more efficient, flexible and individua-
lized models of care in which type, intensity and durations of interventions may better
match the individual needs of the participants (Kordy et al., 2006) than what is currently
the case in most face-to-face and e-mental health settings.
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Technology-enhanced monitoring 363
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